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15010023NO CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10420 BUBB RD CONTRACTOR: BOTHWELL PERMIT NO: 15010023 CONSTRUCTION CORP OWNER'S NAME: HOME OF CHRIST CH CUPERTINO LLC 1590 INDUSTRIAL AVE DATE ISSUED: 02/10/2015 OWNER'S PHONE: 4085067752 SAN JOSE, CA 95112 PHONE NO: (408) 298-8049 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL , License Class Lic. # �Tj �-�` f T -MOBILE - TEMPORARILY MOVE (E) CELL SITIE FROM ONE - Ade/� AREA OF ROOF TO ANOTHER, FOR ACCESS P>iJIE'OSES Contractor `/ 7b 1, to e �f�, f� FOR I hereby affirm that I am licensed under the provisions of Chapter 9 RE -ROOFING (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the Sq. Ft Floor Area: Valuation: $10000 rformance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this APN Number: 35720038.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. 1 agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAB'S OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 1$Q D ROM LAST CALLF� SPECS I Ne indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the 2 1 1 granting of this permit. Additionally, the applicant understands and will comply ssu Date: with - oint source regulati s per Cupertino Municipal Code, Section 9.18. Signatu ate �;?= (O—( S� RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER -BUILDER DECLARATION Signature of Applicant: Date: 1 hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BET'T'ER I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should I store or handle hazardous I have and will maintain a Certificate of Consent to self -insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District 11 performance of the work for which this permit is issued. will maintain compl' ce um ' with the Cupertino al Code, Chapter 9.1L2 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety C e, ions 25505 255 , and 5534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized a permit is issued. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, l CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked, work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date (CUPER-TONO C OO M317RUC7110H PER 07 APPLOCA'ROM COMMUNITY DEVELOPMENT DEPARTMENT o BUILDING DIVISION 10300 TORRE AVENUE o CUPERTINO, CA 95014-3255 (408) 777-3228 ^ FAX (408) 777-3333 o buildingecupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION ® ALTERATION / TI ❑ REVISION/ DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS 10420 Bubb Rd Cupertino, CA 95014 APN # 357-20-038 OWNER NAME Home of Christ Church (Elder James Wang) PHONE 408-506-7752 E-MAIL jameswang316@yahoo.com STREET ADDRESS 10420 Bubb Rd CITY, STATE, ZIP Cupertino, CA 95014 FAX CONTACT NAME T-Mobilec/o Kevin Bowyer w/ Modus ( �'Y Inc)) —7 HONE 408 ( ) 219-5442 E-MAIL kbowyer@modus-corp.com STREET ADDRESS 149 Natoma St 3rd Floor CITY, STATE, ZIP San Francisco, CA 94105 FAX ❑ OWNER ❑ OWNER -BUILDER pl OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME 6 LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITEC NGINEER NAME Bret McComb LICENSE NUMBER C 69891 BUS. LIC # COMPANY NAME Precision Design E-MAIL bret@pdnd.com FAX STREET ADDRESS 1 1768 Atwood Rd Suite 20 CITY, STATE, ZIP Auburn, CA 95603 PHONE (530) 823-6546 DESCRIPTION OF WORK Temporarily relocate T -Mobile's rooftop antennas so the property owner can reroof the existing building. T -Mobile's antennas are currently located on a parapet wall in the middle of the roof. The antennas will be relocated to the edge of the roof. EXISTING USE PROPOSED USE CONSTR. TYPE #STORIES Office Office 2 USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG AREA N/A NEW FLOOR AREA N/A DEMO AREA N/A TOTAL NET AREA N/A $10,000 BATHROOM KITCHEN OTHER REMODEL AREA N/A REMODEL AREA N/A REMODEL AREA N/A PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH N/A N/A N/A ❑ ATTACH N/A # DWELLING UNTIS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES O BEING ADDED? []NO ADDITION? N/A []NO PRE -APPLICATION YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ S TAL VALUATION: PLANNING APPL # NO PLANNING APPROVAL LETTER EICHLER HOME? NO $10,000 By my signature below, I certify to each of the following: I am the property owner or authorized age o ac a property owner's behalf l have read this application and the information I have provided is correct. I have read the Description of Work and ven It is accurate. I agree to comply with all applicable local ordinances and state laws relating to bui 'ng constru 'on. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Date: Signature of Applicant/Agent: SUPPLEMENTAL INFORMATION REQUIRED PLANCHECKTYPE ROUTING SLIP ❑ OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW —New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT X Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH B1dgApp_2011.doc revised 06/21/11 CITY OF SCUP ERTINO FEE ESTIMATOR - BUILDING DIVISION NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the Preliminary information available and are only an estimate. Contact the Deptfor addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff' 7/1/13) ADDRESS: 10420 BUBB RD P/r;n1h. 1'/w; ChrcI DATE: 01/06/2016 REVIEWED BY: MELISSA Phrmh. Pwrrail lee APN: 357 20 038 BP#: *VALUATION: j$10,000 *PERMIT TYPE: Building Permit Wech. Lt�p. 1""', PIAN CHECK TYPE: Alteration / Addition / Repair PRIMARY USE: Commercial Building Permit Fee: Hourly Only? o Yes ) No PENTAMATION PERMIT TYPE: 1GENCOM FORK TEMPORARILY MOVE E CELL SITE FROM ONE AREA OF ROOF TO ANOTHER FOR ACCESS SCOPE PUPOSES FOR RE -ROOFING NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the Preliminary information available and are only an estimate. Contact the Deptfor addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff' 7/1/13) ltech. I'/on Check P/r;n1h. 1'/w; ChrcI hlc, ; n C'h_e llVIII. Pernul Phrmh. Pwrrail lee ! lFer!: of"Icr 1Icch. ln.r;'- Other PiIan lni ;., (i"cl '.; h1 q; Wech. Lt�p. 1""', Phu;th. bus/). I've. 1.1"t J V.,. l'ri ' NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the Preliminary information available and are only an estimate. Contact the Deptfor addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff' 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? C) Yes) No $0.00 hours Plan Check, Hourly $286.00 ISTPLNCK Suppl. PC Fee: Q Reg. C OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? o Yes ) No $0.00 Suppl. Insp. Fee:Q Reg. Q OT 0 0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tin: A.dinini. tralive Fee: 0 E) Work Without Permit? 0 Yes (D No $0.00 Advanced Planning, Fee: $0.00 Select a Non -Residential G Building or Structure 0 C T c�t'el' C)orrulra'r3ta/ivn Fee Strong Motion Fee: IBSEISAIICO $2.80 1.0 hrs Inspections $143.00 ISTINSP Inspection, Hourly Bldg Stds Commission Fee: IBCBSC $1.001 SUBTOTALS: $3.80 $429.00 TOTALFEE: $432.80 Revised: 10/01/2014 P- Q SiA.TEi1rREPdi OF 1K N P tMilT• tLD GCOMM LINiTY DEVELOPMEoiVISiON ALBERT SALVADOR, P.E., C.B4O., BUILDING OFFICIAL CUP6RTIP10 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • bwlding0cupertino.ora SITE ADDREESSS /O fZO CoDer �&5 `ef APN the inspections shall be submitted prior to issuance of a Certiti Owner7pmC$....Q1� ..................... .............................. .......... ..... CoCtor...................,.............................._.....,..................................... Address..l.(�.Q...��..i.(�....................... ...... . Address........................................................................................... cityl5t lv,P.<..C�Afl., .i�.... zp_iS0.1LI. ...,,..Phone. J�?' i3L City/Si.... ....... ......... ............... ........... Zip...... ............. Phone ..... ............. .... Applicant ..1.-MOb �Ic ..,. 09 iJlo u.�... Kev►�, �Qw ¢ `'� En ineedArchitect.. � ? �'i► g ................ . Address )LI jVafOs...g�, �`�...�)Oqr 1���®©G7 B<Cef....[� Address ..., ........... ................ ...... . L citylSt..J.Gn...&-!..1C gLQ.f .L.F .. Zip....1610�...........Phone.fio!q�j CityiSt"46..4c3'rA...... .........Zipg0?A.;. Phone g�.'.071b PROJECT DESCRIPTION: /' �e%c�a _�l D g:� O l ko &)Q g This "STATEMENT OF SPECIAL INSPECTIONS" is submitted in fulfillment of the requirements of CBC Sections 1704 and 1705, This form is structured after and used by permission from the Slructural Engineer Association of Northern California's (SEAONC) mode statement of Special Inspections. Also, included with this form is the following: ❑ "LIST OF SPECIAL INSPECTION AGENCIES (page 2). A list of testing agencies and other special inspectors that will be retained to conduct the tests and inspections for this project ❑ 'SCHEDULE OF SPECIAL INSPECTION' (page 3 — 6). The Schedule of Special Inspections summarizes the Special Inspections and tests required. Special Inspectors tAII refer to the approved plans and specifications for detailed special inspection requirements. Any additional tests and inspections required by the approved plans and specifications shall also be performed. Special Inspections and Testing wilt be performed in accordance with the approved plans and specifications, this statement and CBC Sections 1704, 1705, 1706, 1707, and 1708. Interim reports will be submitted to the Building Official and the Regislered Design Professional in Responsible Charge in accordance with CBC Section 1704.1.2. A Final Report of Special Inspections documenting required Sp lal lnspe the inspections shall be submitted prior to issuance of a Certiti to of UsendOcc document: � p� I�� �.._ a Required special inspections. o Correction of discrepancies noted in inspection A ( J �T The Owner recognizes his or her obligation to ensure that I co tructi implement this program of special inspections. in partial fulfi n nt of the o g ti+ Special Inspections as required in CBC Section 1704.1. LL XPpF `vim e m documents and to Owner will retain and directly pay for the in 0241 , " , S, 06 I I I a . MAP' MR This plan has been developed,,vith the understanding that the Building Official will Review and approve the qualifications of the Special Inspectors who will perform the inspections. Monitor special inspection activities on the job site to assure that the Special Inspectors are qualified and are performing their duties as called for in this Statement of Special Inspection. Review submitted inspection reports. Perform inspections as required by the local building code. I have read and a tee to comply with the terms and conditions of this statement Prepared By: Project 0 Engineer 0 Architect y Registered Design Profession in Char aSi ............. ............tic.# .......... ... ............... Dale:... �.._ Ownsv�Vame: /\ P 1�s Authorization Si nature .. ..................... ........... _...... ..................... .........., .... Date' Inspection Agency l Inspector Name* iQyg rva2 $ S1 nature ......... ......Uc#................................. Date 1/44 Building Official or de ignee, OP*�,� Signature... ........ ... ....... Specirrhi.ryjrcrfalrForrn 2012.doerevisar109106112 r— LIST OF SPECIAL INSPECTION ACENCDES APPROVAL OF SPECIAL INSPECTORS: Each special inspection agency, testing facility, and special inspector shall be recognized by the Building Official prior to performing any duties. Special Inspection agency's listed on this form must be pre -approved and listed on Cupertino's approved Special Inspector's list. Special inspectors shall carry approved identification when performing the functions of a special inspector. Identification cards shall follow the criteria set by the California Council of Testing and Insoection Agencies. No personnel changes shall be made without first obtaining the approval of the Building Official. Any unauthorized personnel changes may result in a "Stop Work Order" and possible permit revocation. To be pre- approved by the City of Cupertino, refer to the SPECIAL INSPECTION CRITERIA handout. Please allow two weeks to complete the application process. The following are the testing and special inspection agencies that will be retained to conduct tests and inspection on this oroieel. EXPERTISE FIRM f INSPECTOR INFORMATION' 1, Special Inspection (except for Firm,........ g(j.i�:�Jf�6�...... 9412r4Ot....Addr....a° �5. .. •........l1.. ai1L:. ..t�S\l�'.... geotechnical) City.............. cr,.¢N�... imc ............... _.J........ ... ......... ,....... .... Slate Telephone Email 2. Material Testing Firm ..................................................... _.....,.Addr....... ....... ........................................ .... ...._ .. city........................... ..... ................................. ........... State ._................ Zip ..................... Telephone......................................Fax....................................... Email.................................................. 3 Geotechnical Inspections Firm ...................................... ............Addr............................................................................. City............... .................................... ............................._..,............. .. State ......................Zip ....... ........ ... . Telephone.................................... Fax .................. ........ ..,...._....Email..... ..... .,............... ............. ...... 4. Other: Firm ................................. ...... ........................... Addr ....... ............ ............................................................... . City................................................... ................................. I...... State ...................zip .................. . Telephone............................... Fax .......... ........... .......... ......... Email ..... _..... .................................. 'All agencies specified on this form must be pre -approved and listed on the City of Cupertino s Approved Special Inspector's List. SEISMIC REQUIREMENTS (Section 1705.3.6) Description of seismic -force -resisting system and designated seismic systems subject to special inspections as per Section 1705.3: The extent of the seismic -force -resisting system is defined in more detail in the construction documents. tura Description of main wind -force -resisting system and designated wind resisting components subject to special inspections in accordance with Section 1705.4.2: The extent of the main wind -force -resisting system and wind resisting components is defined in more detail in the construction documents_ SpeciahispecrionFor» x_2012 doc mvised 09106112 P , , VERIFICATION AND INSPECTION C P REFERENCED IBC STANpARD REFERENCE INSPECTION OF CONCRETE 1. ❑ Inspection of reinforcing steel, including prestressing X ACI 318: 3.5, 7.1-7.7 1913.4 tendons and placement. 2. ❑ Inspection of reinforcing steel welding in accordance AWS D1.4 ACI 318: with Table 1704.3 Item 5b. _ 3.5.2 3, ❑ Inspection of bolts to be installed in concrete prior to and during placement of concrete where allowable X __ ACI 318: 8.1.3, 191 1.5, 1912.1 loads have been increased or where strength design 212.8 is used. 4. ❑ Inspection of anchors installed in hardened concrete. --- X ACI 318: 1912.1 5. ❑ Verifying use of required design mix. 1904.2.2,1913.2, _-- X ACI 318: 1913.3 6. ❑ At time fresh concrete is sampled to fabricate ASTM C 172 specimens for strength tests, perform slump and air X --- ASTM C 31 1913.10 content tests and determine the temperature of the concrete. ACI 318: 5.6, 5.8 7. ❑ Inspection of concrete and shoterete placement for X -- AC 1318: 5.9, 5.10 1913.6. 1913.7, proper application techniques. 1913.8 8. ❑ Inspection for maintenance of specified curing X ACI 318: 5.11-5.13 1913.9 temperature and techniques. 9. Inspection of prestressed concrete: ❑ Application of prestressing forces. X --- ACI 318: 18.20 ❑ Grouting of bonded prestressing tendons in the X --- ACI 318: 18.18.4 _ seismic force -resisting system. 10. ❑ Erection of precast concrete members. -- X ACI 318: Ch. 16 --- 11. ❑ Verification of in-situ concrete strength, prior to stressing of tendons in posttensioned concrete and X ACI 318: 6.2 --- prior to removal of shores and forms from beams and structural slabs. 12. ❑ Inspect formwork for shape, location, and dimensions _ X ACI 318: 6.6.1 of the concrete member being formed. 13. 11s6olts Installed in Existing Masonry or Concrete i ❑ Direct tension testing of existing anchors. --- X See ICC ES Reports form special inspection requirements for proprietary products ❑ Direct tension testing of new bolts. --- X torque testing of new bolts. __ X ❑ Prequalification test for bolts and other types of X anchors. - 14. ❑ Other: 5pet'inG�.tiN�criuuFonei_?Ul3 floc rerlscd UJ/06t1?